Provider Demographics
NPI:1053878603
Name:GOUGE, JARED DOUGLAS
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:DOUGLAS
Last Name:GOUGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:249 LAUREL RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:OLD FORT
Mailing Address - State:NC
Mailing Address - Zip Code:28762-9712
Mailing Address - Country:US
Mailing Address - Phone:828-442-9429
Mailing Address - Fax:
Practice Address - Street 1:249 LAUREL RIDGE DR
Practice Address - Street 2:
Practice Address - City:OLD FORT
Practice Address - State:NC
Practice Address - Zip Code:28762-9712
Practice Address - Country:US
Practice Address - Phone:828-442-9429
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-01
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC233191163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse